Title

Author

Degree

Doctor of Philosophy

Program

Health and Rehabilitation Sciences

Supervisor

Lorelei Lingard

Abstract

This dissertation explores team-based care for patients with advanced heart failure (HF), especially care practices associated with integrating palliative care. Its three integrated articles explore advanced HF care as a team-based health care phenomena, focusing on both objects and people as integral for team activity. The dissertation utilizes the theoretical framework of sociomaterialism to explore the overarching research question: how do materials mediate and influence the integration of palliative and cardiac care for patients with HF? Study data take the form of 15 team sampling units (TSU), each of which consists of a patient interview and an interview with at least one caregiver and one health professional identified by that patient as members of their care team. Data were analyzed through the lens of actor-network theory (ANT).

The first study delves into the sociomaterial underpinnings of HF self-care, focusing on patients and caregivers involved with fluid management in their domestic lives. The study highlights the material effects of fluid and its management for patients and caregivers, as well as the way these material effects build into wider network effects. The manuscript discusses how ANT can enrich recent calls in the HF self-care literature for increased attention to `context' in HF self-care.

The second study explores how our understanding of health care teamwork shifts when materials, like fluid, are described as actors on the HF team. The paper describes the agency of fluid, a heretofore taken-for-granted material in descriptions of team-based HF care. Fluid is a matter of concern at the centre of interprofessional collaboration between cardiologists and nephrologists. The study advances one of the core theoretical insights of my dissertation,---collaborative entanglement---an innovative construct for understanding and reconceptualizing phenomena that researchers and policymakers frequently label `interprofessional collaborative tensions'.

The third study directly engages the ideas and values of palliative care integration for HF. The paper argues that while sociological explanations are crucial to policy programming around palliative care (PC) integration, they are insufficient for fully appreciating the challenges faced by HF care teams who are actively trying to integrate PC. The paper attempts to answer the question: why does palliative care integration fail even when human roles are clear, local culture is supportive, and team knowledge is accurate? ANT is invoked to re-frame the discussion about `under-utilization' of PC services for patients with HF.

Each of these three analytic projects contributes to a growing interest in sociomaterialism amongst medical education researchers in Europe and North America. In the final chapter, key ideas from the overarching analysis are explored alongside methodological reflections. While the focus of this study is fluid, hopefully these results and insights can inspire further innovative sociomaterial inquiry in medical education.